Treatment and Quality of Life of Heart Failure Patients

Treatment and Quality of Life of Heart Failure Patients Compliance to treatment and quality of life of Sudanese patients with heart failure Mugahed AL-khadhera,*,Imad Fadl-Elmulab ,Waled Amen Mohammed Ahmedc Abstract Background: Heart failure is known to decrease the quality of life, especially in non-compliance patients with regards to medications and life style changes. Objective: The present study aimed to determine the level of compliance to treatment and quality of life of Sudanese patients with heart failure. Methods: This descriptive study was conducted on 76 patients with heart failure admitted to the Sudan Heart Institute. Demographic and clinical data including the compliance (medication, sodium restriction, fluid restriction, daily weights, exercises, and appointment-keeping) were collected. The quality of life was measured using the Minnesota living with heart failure Questionnaire. The data were collected from all patients and the analyzed using SPSS version 22 software. Results: Heart failure patients showed low compliance ranged between 11.84% and 75% of which the highest compliance was to medication (75%) followed by the follow-up appointments (71.05%), and the lowest compliances were to the fluids restrictions (11.84%), the weight monitoring (17.10%), regular exercise (21.05%), and the sodium restriction (27.6%). Quality of life score ranged between 62-97 score and the Mean (SD) 83.6 (7.82) which reveled of poor quality of life in most of Sudanese patients with heart failure involved in the present study. Conclusion: The study showed that patients with heart failure in Sudan have low compliance to treatment and poor quality of life. Key words Heart Failure, Treatment Compliance, Quality of life, Sudan Introduction: Heart failure incidence increases with age, increase from approximately 20 per 1000 individuals with age 65 to 69-year-old to more than 80 per 1000 individuals aging 85-year-old (1). In fact few epidemiological data on heart failure in Sudan exists and the recognition of the disease as a major health issue remains questionable, the prevalent of heart failure accounts for 2.5% of the population, and hence it is one of the major causes of hospital mortality (2). The WHO defined adherence as extent a person’s behavior –taking drugs, following a diet, and/or executing lifestyle modifications, follow the agreed recommendations from a health care providers (3). Poor compliance â€Å"noncompliance† usually refers to patients’ failure to follow health interventions as recommended by the health care provider, but it can also refer to the providers’ failure to act according to practice guidelines or standards of care(4). The factors affecting the compliance could be divided into patient-related factors, regimen-related factors, and health care providers-related factors (5). Non-compliance to medications and diet contributes in many cases to worsening heart failure symptoms. The compliance to prescribe medications or other caregivers recommendations such as lifestyle changes is a widely acknowledged problem leading to hospitalization ((6-8). The non-compliance of HF patients is a major problem and remains to be a continuous source of concern for patients. It is mainly for diet and fluid, daily weight and exercises (9). Quality of life (QOL) is defined as the individual’s unique cognition and a way to express feelings about his/her health status(10).Moreover, QOL is a good predictor of mortality and the need for hospitalization (11-13). Patients in class II and III heart failure of New York Heart Association (NYHA) classification cannot normally do their daily activities (9). Although, several studies on compliance of HF patients and their quality of life have been performed worldwide, to our knowledge this is the first ever study conducted in Sudanese HF patients, aimed to assess the compliance to treatment and quality of life in Sudanese patients with heart failure. Materials and Methods This descriptive study was conducted on 76 patients with heart failure admitted to the Sudan Heart Institute. A total of 76 Sudanese HF patients were randomly selected from Sudan Heart Institute in Khartoum, January-March 2014. The patients participated were above 20 years, confirmed diagnosed as heart failure by the cardiologist at least a month, already start HF treatment, in class II or III heart failure of NYHA, and with ability to communicate. The questionnaire consists of 36 questions of which 10 for demographic and clinical data, 5 questions for compliance, and 21 questions for quality of life. Demographic and clinical data were collected from medical records and/or by interviews. The demographic data included age, gender, educational level, and marital status, whereas clinical variables include left ventricular ejection fraction (EF), previous hospitalization in the past three months, and duration of HF. Revised HF Compliance Questionnaire was used (14), on a five-point scale (1=‘never’; 2= seldom; 3= half of the time; 4 =mostly; 5=‘always’) (15). the participant’s compliance to medications, diet, fluid restriction, exercise, weight, and appointment keeping was evaluated by asking patients to rate their compliance of the last week (drugs, diet modifications, fluid restriction, and exercises), the last month (daily weighing), and the last 3 months (appointment keeping) before hospitalization. The patients were divided into two groups; either compliant or noncompliant (16-19). Patients were considered ‘overall compliant’ the compliance with four or more of the six recommendations.(20) (Table 2). The quality of life data were collected and measured using the Minnesota Living with Heart Failure Questionnaire after translated to Arabic language (9). This instrument used most widely to evaluate quality of life in research studies (21-24) .Which Contains 21 questions and overall score of 105 (521) with possible answers ranging from 0 (no) to 5 (very much), (0= no; 1= Very Little ; 2= little: 3= moderate; 4= much; 5= very much). The final score is the sum points obtained for the 21 questions; it can therefore vary between 0 and 105. It evaluates how heart failure affects patients ‘physical (8 questions), emotional (5 questions), and socioeconomic (8 questions) dimensions (25). The sum of responses reflects the overall effects of heart failure and treatments on individual’s quality of life (9). Data was presented using descriptive statistics including frequency, percentage, mean with standard deviation (SD) and P-value of ≠¤0.05 was considered statistically significant for relationship investigations. Ethical approval was obtained from Al Neelain Ethical committee at Al Neelain University. All patients signed an informed consent before participate in the study. Results The study showed that out the 76 patients, 63.2% were male and 36.8% were female; the mean age was 61.4  ±13.5 years. The education levels were 34.2% of patients were illiterate, 32.9% had completed primary school, 19.7% secondary school, and 13.2% had university graduation (Table 1). Although the vast majority of the patients were chronic patients with diagnosis for more than 5 years, the participant ask to define what is the heart failure? Only 24% had basic conscious about their disease, the remaining 76% of patients had no idea what the heart failure is. Overall compliance among the patients was 28.95%, whereas 71.5% of the patients were classified as non-compliant. Of those compliance with medication was 75% and 70% compliance with appointment-keeping. In general most patients showed low compliance with diet restriction (27%), exercise (21%), weighing (17%), and fluid restriction (11%) (Table2). The quality of life data showed that poor quality of life, the score ranged from 62-97 score /105, and the Mean (SD) quality of life was 3.2 (1.3) which reveled of poor quality of life in most of Sudanese patients with heart failure involved in the present study .There is statistically significant in compliance and quality of life (p value= 0.002) in compression with patients who is noncompliant. Also statistically significant with improved NYHA classification, LVEF and quality of life (pTable 3). (Table.1): Demographic and clinical variables of the study population (n=76) in Sudan. (Table.2) Compliance (Medications, diet, Fluid restriction, Exercise, weight, and appointments keeping) in Sudan. (Table.3) Quality of life of heart failure patients in Sudan (N=76) Discussion The patients’ compliance in this study ranged between 11.84% and 75% of the patients. Although the differences in measurement instruments and differences in interventions, the result of the this study showed low compliance compared with other previous studies including knowledge of the patients about their illness, the hazard of high salt consumption, and the daily weighing. Study done by Baghianimoghadam MH, et al, reported that the disease knowledge in Iranian patients reached 38% (26), whereas our result showed that 76% of HF Sudanese Patients lack essential knowledge of their disease or what the heart failure is. According to definition of ‘overall compliance (16).The overall patients’ compliance of the present study was 28% compared with the study conducted by van der wal in which the overall compliance reached 72% of patients with HF(16). In the same study compliance with medication (98.6%), appointment keeping, salt restriction (79%), fluid restriction (73%), exercise (39%), and weighing (35%) where all higher compared with the results of the present study(16). Also the compliance level of present study is lower than Evangelista study which found higher levels of compliance more than 90% for (follow-up appointments, medications, smoking, and alcohol cessation), low compliance dietary 71% and exercise recommendations 53% (17). Medicati on compliance in the present study result is similar to the study done by kamlovi yayhd which found 74.7% that compliance to medication (27). This may be a reflection of lack of knowledge and training programs offered to HF patients in Sudan. The Minnesota living with heart failure questionnaire (MLWHFQ) showed that poor quality of life, the score ranged between 62-97 score /105, and the Mean (SD) quality of life was 83.6 (7.82) which reveled of poor quality of life in most of Sudanese patients with heart failure involved in the present study . It was also found that no correlation between age and quality of life (p value =0.925) ,this similar to study done by Kato N,et al (28), some studies found association between age and quality of life (29). We did not observe sex differences in quality of life ( p value =0.99 ), which similar to study done by Heo S, et al 2007 (29). But other studies have reported quality of life worse in female (30;31). Also we found marital status had no influence on QOL in our subjects (p value =0.34) , it is lower to study done by Luttik ML, which found differences in QoL between married patients and those living alone were most pronounced with regard to future expectations of QoL (6.5 vs 5.0, P=.00 (32). Our study shows there is statistically significant in duration of disease with QOL (p value =0.004), Also statistically significant with improved NYHA classification, LVEF and Quality of life (p In this study, the researcher found that total compliance was poor for HF Sudanese patients, compliance for drugs and appointments keeping were high but still in an unacceptable level. Compliance with diet, fluid restriction, activity and daily weighing was low. Also the study revealed that non-compliance negatively affects the quality of life of Sudanese HF patients. Based on result of present study, education and counseling are extremely needed to increased patients-knowledge about their disease, leading to more compliance and improvement of their quality of life.

Managing Church Conflict

Managing Church Conflict Conflict within Churches continues to be a problem (Tony Cartledge 2001), and it shows little sign of abating. In fact, the opposite could be much closer to the truth. Perhaps this is why so many in the ministry turn to the writings of Hugh Halverstgadt (2002), a ministry professor from Chicago. In the introduction to his book â€Å"Managing Church Conflicts†, Halverstgadt analyzes the personal and congregational reasons that provide the root causes, which can lead from minor disagreements to outright conflict. His book develops the theme that, as in many areas of life, to sensibly address these problems, ministries and churches globally need to institute a system of conflict management. Leading the reader through a step-by-step conflict management strategy, covering a wide range of typical scenarios, Halverstgadt leads us to his image of peace in churches based upon the notion of Shalom, which promotes the â€Å"right harmonious relationships to other human beings,† (Nicholas Wolterstorff, 1983).   The real question is whether the views held, and the solutions that Halverstgadt promotes to resolve conflict, address the situation. Halverstgadt’s preface asks the question â€Å"can Church conflict be Christian?† and argues that where it degenerates into a â€Å"dirty fighting† scenario, which is not uncommon, this is perhaps not the case. To address this he suggests that ways of turning such disputes into a â€Å"fair† Christian fight need to be found. However, he accepts that there is no need for the Church to fear conflict, provided it is engaged in a manner of fairness. He provides an insight into the reasons conflicts, identifying that essentially the foundation for all conflict is power and that power turns to conflict once its balance is disturbed. Such disturbances can one sector seeks to promote its power in a way that other may perceive would result in a weakening, and therefore limiting or reducing, the power that they think they should enjoy. As, in the case of the Church, most conflicts are deemed centered round power battles within the congregation itself, the book promotes the theory that it falls to the pastor or minister to take on the mantle of conflict manager. It suggests that to successfully take on and execute the role, the manager will needs to reassess their own ideas and beliefs in terms of conflict and their reactions to a situation that arises. In effect, Halverstgadt is looking to the conflict managers to retrain themselves into this new role so that their approach will lead to a solution to the issue that will be acceptable to all of the parties concerned. He acknowledges that the force nature of such a role may be alien to the person, but counsels that as long as they approach it from a position of self-worth, a knowledge that one is a loved member of God’s and the communities family, others will respond positively to them. Part two of â€Å"Managing Church Conflicts† concentrates on the understanding of the issues that have given rise to the conflict, and analyzing these issues and the parties involved into their component parts. One of the first steps advocated is to set rules for the discussion of the conflict, which may mean reorganizing the current ways that existing systems of debates within the Church and its congregation are managed. Often, in conflict situations, both the root causes and indeed the participants in the dispute are not easily identifiable. Therefore, the book suggests that there is a need for the conflict manager to move between the disputing parties and draw them together in conversation that is open and productive. One of the first, and most important, steps in this process includes ensuring that the disagreements move from a â€Å"dirty fighting† stance, which is characterized by its personal direction and content, to an open discussion based upon the foundation of Christian ethics. Haverstadt suggests that it is only once all of these issues have been addressed that the ministry or pastor can move onto the next step, which is the task of managing the conflict and bringing about a resolution that is just, fair and brings about unity once again. Haverstadt further recognizes that managing a conflict situation is no easy task, even for the most experienced conflict manager, and that is has certain limitations. Therefore, in the second part of his book, he sets out a straightforward systematic process for the church mediator to follow.   How they can avoid damaging exchanges between the parties, partially by using the interpretations of faith on the issues, and seeking calmer methods of controlling the discussions. He further discusses ways in which this process should not be limited to just the main protagonists as this could bring about the arising of new conflicts, but include the Church community, so that everyone understands where the process is heading. Furthermore, recognizing that there are issues within the individuals involved that might be better served in private, he suggests that the using of a mentor, or coach, may be beneficial. This gives the individuals the opportunity to discuss those feelings on a personal basis, and to receive comfort and counseling from those appointed to assist them. The desire is that this will lead to a situation where parties can put forward the basis of their strategies and arguments in a positive and clearly defined manner. In the relative calmness of discussion that these moves are hoped to produce, Haverstadt’s book then attempts to deal with the subject of resolution itself, outlining the strengths and weakness of the possibility of trying to reunite the differences or achieving a negotiated settlement acceptable to all. The whole focus or aim of the procedures that Haverstadt’s book promotes is the perception that, by following the guidelines outlined, a position of shalom will be reached. Shalom, in the biblical understanding of the term, a vision which emphasizes the notion of a united, just community bound in pleasant relationships. Although this may seem to exclude discord and diverse viewpoints, as Haverstadt explains, this is not the case. Diversity in the vision of shalom is realized and accepted within an enthusiastic wish to maintain and restore relationships with others using the one abiding link between the congregation, namely their belief in God and the trilogy. Differences in this situation become part of the core strength of the community, rather than the influence that tears the community apart. Result To the extent that the focus of Halverstgadt’s interpretation that the causes of Church conflict are produced by a clashing of power bases, there is little evidence to argue against his findings. If one looks at the development of the Christian Church over the centuries since it’s birth with the death of Christ, the power theory is evidently supported. From a that one focus, Christianity, one has seen it develop into a multi-faceted structure, with the only link, and that somewhat precarious, being the core belief in the trilogy. Catholic, Anglican, Baptist and Methodist, amongst a host of Churches, ostensibly promote the same message, all offering the same vision for the salvation of the human being. Yet, when reflecting about each other, the divisions are obvious, sometimes almost vitriolic in their expression. Historically, it is clearly demonstrated that these divisions resulted from a conflict of power. A typical example is the way in which the King of England separated the Anglican Church from the Church of Rome. Halverstgadt’s promotion of the use of conflict management in an effort to resolve Church conflicts, by providing a calm and common sense vehicle through which issues can be identified and resolved is laudable. Such systems have been used as an integral part of human resource management in business for a number of years, often with much success. However, like all strategies, it has its limitations. Successful conflict management in a community relies upon all the protagonists having the same goals. Business is possibly unique, in that all involved have a tangible focus for conflict management, the business itself. The difference with Church conflicts is that although much of the dispute is about power, it also rests in emotions and non-tangible ideas and beliefs. For example, some of the congregation would promote the idea that the Church should accumulate wealth, so that it can promote its message from a position of strength, others promote the idea that strength of message is better served and more honest from a position of meekness. Conclusion My opinion of this book is that it will serve as a good foundation for dealing with Church conflicts in a number of instances, the main areas to benefit from this good will be concentrated on a parochial basis. At the level where major conflicts occur, as identified in the example of conflict between King of England and the Church of Rome, the power driven differences are too embedded within the psyche of the dominators of the various factions for mediation to be truly successful. In addition, whilst the vision of Shalom is a worthy target for all communities, particularly in Churches, such is the nature of the Human Being that it is unlikely the culmination of this vision will come to fruition. My conclusion therefore is that, whilst the book provides valuable direction from which the Church, its concentration and examples are too localized to make a significant impact upon the area where it is needed most, namely the hierarchy of the various religious sects themselves. References Halverstgadt, Hugh. F. (1992). Managing Church Conflict. Westminster/John Knox Press. U.S. Cartledge, Tony. W.   ed. (2001). Church conflict a common problem. Biblical Recorder. North Carolina. U.S.A. Wolterstorff, Nicholas (1983). Until Justice and Peace Embrace Grand Rapids: Eerdmans. p 70.               

Learning from LeapFrog Essay

1. What was the Leapfrog business model at the time that the company launched its first products and services? How did the business model change over time? 2. Who are LeapFrog’s key stakeholders? How does LeapFrog deliver value to each of these stakeholder groups? 3. At the time of the case, Leapfrog had become the #3 consumer toy company in the U.S. behind #1 and #2, Mattell and Hasbro respectively. What factors contributed to Leapfrog’s success? Do you expect the success to continue in the future? 4. What challenges and opportunities does the company face in early 2003? Would you buy stock in Leapfrog? Why or why not? As an independent member of the company’s board of directors, what would you expect of management in the short-term and long-term? How would you fulfill your fiduciary duties to the company’s shareholders? Canyon Ranch 1. What is the value of customer information to Canyon Ranch? 2. 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The IPremier Company CEO, Jack Samuelson, had already expressed to Bob Turley his concern that the company might eventually suffer from a â€Å"deficit in operating procedures.† Were the company’s operating procedures deficient in responding to this attack? What additional procedures might have been in place to better handle the attack? 3. Now that the attack has ended, what can the IPremier Company do to prepare for another such attack? 4. Describe the ethical implications of not being sure if credit card numbers had been stolen. What options do you have in the struggle to be an ethical vendor, yet to stay in business? What actions would you take? 5. In the aftermath of the attack, what would you be worried about? What actions would you recommend? Strategic Outsourcing at Bharti Airtel Limited 1. What must Bharti do well to succeed in the Indian mobile phone market? What are Bharti’s core competencies? 2. Do you think Bharti should enter the outsourcing agreements outlined by Gupta? What do you see as advantages and disadvantages of such agreements? How do the different outsourcing agreements work towards building these core competencies? 3. If you were Bharti, what major concerns would you have about entering an outsourcing agreement with IBM? With Ericsson, Nokia, or Siemens? 4. How would you structure the agreements to address your concerns and capture any advantages you have identified? What governance mechanisms would you design for the agreements? 5. Assume the role of IBM or Nokia. What major concerns would you have about entering an agreement with Bharti? How would you structure the agreement and the governance mechanisms? VW of America: Managing IT Priorities 1. What is your assessment of the new process for managing priorities at Volkswagen of America? Are the criticisms justified? Is it an improvement over the old process? 2. Who controls the budgets from which IT projects are funded at Volkswagen of America? Who should control these budgets? Should the IT department have its own budget? 3. How should Matulovic respond to his fellow executives who are calling to ask him for special treatment outside the new priority management system? 4. What should Matulovic do about the unfunded Supply Flow project? The ITC eChoupal Initiative 1. What was ITC’s motivation for creating the eChoupal? 2. What were the old and new physical flows and information flows in the channel? 3. What principles did it employ as it built the newly-fashioned supply chain? 4. What barriers did ITC face in embarking on this project? 5. How should ITC develop this platform for the future?

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